Form SS-16 Certificate of Election of Coverage Send Copies A, B,

and C to the

appropriate IRS

address below.

(Rev. April 2010) Under the Federal Insurance Contributions Act

Department of the Treasury

Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)

Full name of religious order (or autonomous subdivision of religious order) Employer identification number

Address (include number, street, apt., or suite no.) Effective date (mm/dd/yyyy)

(See instructions below.)

City, town or post office, state, and ZIP code (If you have a foreign address, see instructions below.)

Type or print

Under penalties of perjury, I certify that the religious order named above irrevocably elects social security and Medicare coverage for services performed by all our

current and future members in exercising their required duties (which shall be considered services performed as employees of the religious order) and that our

members are required to take a vow of poverty. Each member’s wages, on which we shall pay the social security and Medicare taxes imposed on employees and

employers, will be determined as provided in section 3121(i)(4) of the Internal Revenue Code.

Sign

here

©

(Signature of authorized official) (Title) (Date)

(Print or type name of authorized official) (Telephone number)

Purpose of Form

Effect of Election

Effective Date

● The calendar quarter in which the certificate is

filed,

● The calendar quarter after the quarter in which

the certificate is filed, or

● Any one of the 20 calendar quarters before the

quarter in which the certificate is filed.

Retroactive Coverage

Paying taxes for retroactive coverage. When

coverage is made retroactive to cover one or more

calendar quarters before the quarter in which the

certificate is filed, the religious order must report

and pay the total employer and employee social

security and Medicare taxes for these quarters. File

Form 941 or 941-X, as appropriate, for each quarter.

For details, see Which Form To File on Copy B or D.

Definitions

Member of religious order. For purposes of this

certificate, a member of a religious order is an

individual who (a) is subject to a vow of poverty as

a member, (b) performs the services usually 

required of an active member, and (c) is not

considered retired because of age or total disability.

Wages for member’s services. For purposes of

this certificate, wages subject to social security and

Medicare taxes generally include all pay you give to

a member for services performed. The term “wages” 

also includes the fair market value of board, lodging,

clothing, and other benefits a member receives in

return for services from the order or from any

person or organization under an agreement with the

order or subdivision. If the fair market value of the

items is less than $100 a month, that amount

cannot be included as wages.

How To File Form SS-16

Need help? For help in preparing this form, call the

IRS at 1-800-829-4933 (toll free). If you have access

to TTY/TDD equipment, call 1-800-829-4059 (toll

free). If you are in a foreign country, call

215-516-2000 (not toll free). For information about

the effect of this form on the social security and

Medicare benefits of your members, contact any

Social Security Administration office.

Where To File Form SS-16

If the religious order or

autonomous subdivision is

located in:

File with the Internal

Revenue Service

Center at:

Ä Ä

Connecticut, Delaware,

District of Columbia, Illinois,

Indiana, Kentucky, Maine,

Maryland, Massachusetts,

Michigan, New Hampshire,

New Jersey, New York,

North Carolina, Ohio,

Pennsylvania, Rhode Island,

South Carolina, Vermont,

Virginia, West Virginia,

Wisconsin

Cincinnati, OH 45999

Alabama, Alaska, Arizona,

Arkansas, California,

Colorado, Florida, Georgia,

Hawaii, Idaho, Iowa, Kansas,

Louisiana, Minnesota,

Mississippi, Missouri,

Montana, Nebraska,

Nevada, New Mexico, North

Dakota, Oklahoma, Oregon,

South Dakota, Tennessee,

Texas, Utah, Washington,

Wyoming

If the religious order is

not located in any state

A religious order (or autonomous subdivision of a

religious order) whose members are required to take

a vow of poverty may file Form SS-16 to certify that

it elects social security and Medicare coverage

under section 3121(r) for services its members

perform in exercising their required duties.

This certificate is irrevocable and applies to all

current and future members of the order. All

services a member performs in exercising required

duties are considered performed as an employee of

the order. The order must pay the social security

and Medicare taxes imposed on employees and

employers on the wages, as defined later, of each

active member. The taxes are reported on Form 941

or 941-X, as appropriate. For details, see Which

Form To File on Copy B or D.

This election becomes effective for the period that

begins on the first day of:

When social security and Medicare coverage is

made retroactive to a quarter before the quarter in

which the certificate is filed, coverage applies only

to services performed during the retroactive period

by persons who were active members when the

services were performed and who are alive on the

first day of the quarter the certificate is filed.

An authorized official of the order must sign the form

and send Copies A, B, and C to the appropriate

address listed below under Where To File Form

SS-16. Keep Copy D for your records. Copy C will

be returned to you after the form is accepted by the

Internal Revenue Service (IRS).

File this form with the Internal Revenue Service

Center for the state in which the religious order is

located.

General Instructions

Section references are to the Internal Revenue

Code.

Specific Instructions—

Form SS-16

Enter one of these dates in the space to the right

of the address. If the effective date is incorrect for

your filing date or is missing, Form SS-16 will be

returned.

Department of the Treasury

Internal Revenue Service Center

Ogden, UT 84201

Department of the Treasury

Internal Revenue Service Center

Ogden, UT 84201

Department of the Treasury

Internal Revenue Service Center

This form consists of four pages. Copies A and C

each contain the same general information and

instructions for filing Form SS-16. Copies B and D

each contain the same instructions specific to this

election for filing Form 941, Employer’s

QUARTERLY Federal Tax Return, and Form 941-X,

Adjusted Employer’s QUARTERLY Federal Tax

Return or Claim for Refund.

Foreign Address

Enter the information in the following order: city,

province or state, and country. Follow the country’s

practice for entering the postal code. Do not

abbreviate the country name.

Employer Identification Number

(EIN)

If the religious order already files Form 941, be sure

to show the same EIN on Form SS-16 that you use

on your return.

Telephone number. Enter the best daytime

telephone number, including area code, where we

can reach you if we have any questions.
Form SS-16 Certificate of Election of Coverage Send Copies A, B,

and C to the

appropriate IRS

address on Copy A.

(Rev. April 2010) Under the Federal Insurance Contributions Act

Department of the Treasury

Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)

Full name of religious order (or autonomous subdivision of religious order) Employer identification number

Address (include number, street, apt., or suite no.)

City, town or post office, state, and ZIP code (If you have a foreign address, see instructions on Copy A.)

Type or print

Under penalties of perjury, I certify that the religious order named above irrevocably elects social security and Medicare coverage for services performed by all our

current and future members in exercising their required duties (which shall be considered services performed as employees of the religious order) and that our

members are required to take a vow of poverty. Each member’s wages, on which we shall pay the social security and Medicare taxes imposed on employees and

employers, will be determined as provided in section 3121(i)(4) of the Internal Revenue Code.

Sign

here

©

(Signature of authorized official) (Title) (Date)

Which Form To File

● Order prior-year forms and instructions by

calling 1-800-829-3676. You should receive

your order within 10 days.

● Send your order to the address below.

You should receive a response within 10 days

after your request is received.

● On IRS.gov, click on “Forms and

Publications,” then on “Previous years.” 

Select the year and then scroll down to find

Form 941.

Future quarter. If Form SS-16 is made

effective the first day of the calendar quarter

immediately after the calendar quarter in

which Form SS-16 is filed, then Form 941 is

due the last day of the calendar month

following the calendar quarter.

When To File Forms 941 and 941-X

Current quarter. If Form SS-16 is made

effective the first day of the calendar quarter

in which the Form SS-16 is filed, then Form

941 is due the last day of the calendar month

following the calendar quarter.

Where To File Forms 941 and

941-X

For the current and future quarters, the taxes

are reported on Form 941, Employer’s

QUARTERLY Federal Tax Return.

Form 941. The form that must be filed for

each of the retroactive quarters depends on

whether an original Form 941 was filed for the

specific retroactive period. If Form 941 was

never filed for one or more quarters for which

this election is effective, the religious order (or

subdivision) must file Forms 941 for those

retroactive quarters.

See the current instructions for Form 941 or

941-X for the list of filing addresses.

Specific Instructions— 

Forms 941 and 941-X

IF the Form SS-16

is filed any day

during the . . .

Effective date (mm/dd/yyyy)

(See instructions on Copy A.)

1st quarter (January,

February, March)

Form 941-X. If original Forms 941 were filed

for any of the retroactive quarters for which

this election is effective, the religious order

must file Forms 941-X, Adjusted Employer’s

QUARTERLY Federal Tax Return or Claim for

Refund, for those retroactive quarters.

Form 944. If you were notified to file Form

944, Employer’s ANNUAL Federal Tax Return,

instead of Form 941, call the IRS for

assistance at 1-800-829-4933 (toll free). If you

have access to TTY/TDD equipment, call

1-800-829-4059 (toll free). If you are in a

foreign country, call 215-516-2000 (not toll

free).

Retroactive quarters. Under section 3121(r),

the due date of Forms 941 or 941-X for all

retroactive quarters is determined by the date

Form SS-16 is filed. The due date for filing

the returns and paying the tax, for calendar

quarters prior to the quarter in which Form

SS-16 is filed, is the last day of the calendar

month following the calendar quarter in which

Form SS-16 is filed. If you file and pay by the

applicable due date, you will not be subject

to failure to file or failure to pay penalties or

interest.

THEN all Forms 941 or

941-X for the retroactive

quarters must be filed

and tax paid by . . .

2nd quarter (April, 

May, June)

3rd quarter (July, 

August, September)

4th quarter (October,

November, December)

April 30

July 31

October 31

January 31 of next year

Postmark rule. For purposes of determining

when returns are due, generally the “received

date” is considered the date Form SS-16 is

filed. However, if the religious order selects an

effective date that is the first day of the 20th

calendar quarter preceding the quarter in

which Form SS-16 is postmarked but the

Form SS-16 is received in a later quarter, the

IRS will use the postmark date to determine

the date filed to ensure the intended 20th

quarter can be included.

How To File

Forms 941 for retroactive quarters. Enter

“Form SS-16” and the date you filed Form

SS-16 in dark, bold letters across the top

margin of page 1 of each Form 941 being

filed. Attach a copy of Form SS-16 to each

Form 941 filed for a retroactive quarter to

help identify that the return is being filed for

retroactive coverage. In the top margin of the

Form SS-16 being attached, enter “Copy” in

dark, bold letters.

You can get Forms 941 for the retroactive

quarters by phone, mail, or on the Internet.

Internal Revenue Service

1201 N. Mitsubishi Motorway

Bloomington, IL 61705-6613

Form 941-X. In the explanation in Part IV of

each Form 941-X, enter “Form SS-16” and

the date your Form SS-16 was filed.

If you are filing Form 941-X for any

retroactive quarter, use the current form. You

can get this form through any of the sources

listed above.

Additional information. See Pub. 15 (Circular

E), Employer’s Tax Guide, for more

information about filing or correcting Form

941 or 944. Also see the instructions for Form

941, 941-X, or 944.

(Print or type name of authorized official) (Telephone number)
Form SS-16 Certificate of Election of Coverage Send Copies A, B,

and C to the

appropriate IRS

address below.

(Rev. April 2010) Under the Federal Insurance Contributions Act

Department of the Treasury

Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)

Full name of religious order (or autonomous subdivision of religious order) Employer identification number

Address (include number, street, apt., or suite no.) Effective date (mm/dd/yyyy)

(See instructions below.)

City, town or post office, state, and ZIP code (If you have a foreign address, see instructions below.)

Type or print

Under penalties of perjury, I certify that the religious order named above irrevocably elects social security and Medicare coverage for services performed by all our

current and future members in exercising their required duties (which shall be considered services performed as employees of the religious order) and that our

members are required to take a vow of poverty. Each member’s wages, on which we shall pay the social security and Medicare taxes imposed on employees and

employers, will be determined as provided in section 3121(i)(4) of the Internal Revenue Code.

Sign

here

©

(Signature of authorized official) (Title) (Date)

Purpose of Form

Effect of Election

Effective Date

● The calendar quarter in which the certificate is

filed,

● The calendar quarter after the quarter in which

the certificate is filed, or

● Any one of the 20 calendar quarters before the

quarter in which the certificate is filed.

Retroactive Coverage

Paying taxes for retroactive coverage. When

coverage is made retroactive to cover one or more

calendar quarters before the quarter in which the

certificate is filed, the religious order must report

and pay the total employer and employee social

security and Medicare taxes for these quarters. File

Form 941 or 941-X, as appropriate, for each quarter.

For details, see Which Form To File on Copy B or D.

Definitions

Member of religious order. For purposes of this

certificate, a member of a religious order is an

individual who (a) is subject to a vow of poverty as

a member, (b) performs the services usually 

required of an active member, and (c) is not

considered retired because of age or total disability.

Wages for member’s services. For purposes of

this certificate, wages subject to social security and

Medicare taxes generally include all pay you give to

a member for services performed. The term “wages” 

also includes the fair market value of board, lodging,

clothing, and other benefits a member receives in

return for services from the order or from any

person or organization under an agreement with the

order or subdivision. If the fair market value of the

items is less than $100 a month, that amount

cannot be included as wages.

How To File Form SS-16

Need help? For help in preparing this form, call the

IRS at 1-800-829-4933 (toll free). If you have access

to TTY/TDD equipment, call 1-800-829-4059 (toll

free). If you are in a foreign country, call

215-516-2000 (not toll free). For information about

the effect of this form on the social security and

Medicare benefits of your members, contact any

Social Security Administration office.

Where To File Form SS-16

If the religious order or

autonomous subdivision is

located in:

File with the Internal

Revenue Service

Center at:

Ä Ä

Connecticut, Delaware,

District of Columbia, Illinois,

Indiana, Kentucky, Maine,

Maryland, Massachusetts,

Michigan, New Hampshire,

New Jersey, New York,

North Carolina, Ohio,

Pennsylvania, Rhode Island,

South Carolina, Vermont,

Virginia, West Virginia,

Wisconsin

Cincinnati, OH 45999

Alabama, Alaska, Arizona,

Arkansas, California,

Colorado, Florida, Georgia,

Hawaii, Idaho, Iowa, Kansas,

Louisiana, Minnesota,

Mississippi, Missouri,

Montana, Nebraska,

Nevada, New Mexico, North

Dakota, Oklahoma, Oregon,

South Dakota, Tennessee,

Texas, Utah, Washington,

Wyoming

If the religious order is

not located in any state

A religious order (or autonomous subdivision of a

religious order) whose members are required to take

a vow of poverty may file Form SS-16 to certify that

it elects social security and Medicare coverage

under section 3121(r) for services its members

perform in exercising their required duties.

This certificate is irrevocable and applies to all

current and future members of the order. All

services a member performs in exercising required

duties are considered performed as an employee of

the order. The order must pay the social security

and Medicare taxes imposed on employees and

employers on the wages, as defined later, of each

active member. The taxes are reported on Form 941

or 941-X, as appropriate. For details, see Which

Form To File on Copy B or D.

This election becomes effective for the period that

begins on the first day of:

When social security and Medicare coverage is

made retroactive to a quarter before the quarter in

which the certificate is filed, coverage applies only

to services performed during the retroactive period

by persons who were active members when the

services were performed and who are alive on the

first day of the quarter the certificate is filed.

An authorized official of the order must sign the form

and send Copies A, B, and C to the appropriate

address listed below under Where To File Form

SS-16. Keep Copy D for your records. Copy C will

be returned to you after the form is accepted by the

Internal Revenue Service (IRS).

File this form with the Internal Revenue Service

Center for the state in which the religious order is

located.

General Instructions

Section references are to the Internal Revenue

Code.

Specific Instructions—

Form SS-16

Enter one of these dates in the space to the right

of the address. If the effective date is incorrect for

your filing date or is missing, Form SS-16 will be

returned.

Department of the Treasury

Internal Revenue Service Center

Ogden, UT 84201

Department of the Treasury

Internal Revenue Service Center

Ogden, UT 84201

Department of the Treasury

Internal Revenue Service Center

This form consists of four pages. Copies A and C

each contain the same general information and

instructions for filing Form SS-16. Copies B and D

each contain the same instructions specific to this

election for filing Form 941, Employer’s

QUARTERLY Federal Tax Return, and Form 941-X,

Adjusted Employer’s QUARTERLY Federal Tax

Return or Claim for Refund.

Foreign Address

Enter the information in the following order: city,

province or state, and country. Follow the country’s

practice for entering the postal code. Do not

abbreviate the country name.

Employer Identification Number

(EIN)

If the religious order already files Form 941, be sure

to show the same EIN on Form SS-16 that you use

on your return.

(Print or type name of authorized official) (Telephone number)

Telephone number. Enter the best daytime

telephone number, including area code, where we

can reach you if we have any questions.
Form SS-16 Certificate of Election of Coverage Send Copies A, B,

and C to the

appropriate IRS

address on Copy A.

(Rev. April 2010) Under the Federal Insurance Contributions Act

Department of the Treasury

Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)

Full name of religious order (or autonomous subdivision of religious order) Employer identification number

Address (include number, street, apt., or suite no.)

City, town or post office, state, and ZIP code (If you have a foreign address, see instructions on Copy C.)

Type or print

Under penalties of perjury, I certify that the religious order named above irrevocably elects social security and Medicare coverage for services performed by all our

current and future members in exercising their required duties (which shall be considered services performed as employees of the religious order) and that our

members are required to take a vow of poverty. Each member’s wages, on which we shall pay the social security and Medicare taxes imposed on employees and

employers, will be determined as provided in section 3121(i)(4) of the Internal Revenue Code.

Sign

here

©

(Signature of authorized official) (Title) (Date)

Which Form To File

● Order prior-year forms and instructions by

calling 1-800-829-3676. You should receive

your order within 10 days.

● Send your order to the address below.

You should receive a response within 10 days

after your request is received.

● On IRS.gov, click on “Forms and

Publications,” then on “Previous years.” 

Select the year and then scroll down to find

Form 941.

Future quarter. If Form SS-16 is made

effective the first day of the calendar quarter

immediately after the calendar quarter in

which Form SS-16 is filed, then Form 941 is

due the last day of the calendar month

following the calendar quarter.

When To File Forms 941 and

941-X

Current quarter. If Form SS-16 is made

effective the first day of the calendar quarter

in which the Form SS-16 is filed, then Form

941 is due the last day of the calendar month

following the calendar quarter.

Where To File Forms 941 and

941-X

For the current and future quarters, the taxes

are reported on Form 941, Employer’s

QUARTERLY Federal Tax Return.

Form 941. The form that must be filed for

each of the retroactive quarters depends on

whether an original Form 941 was filed for the

specific retroactive period. If Form 941 was

never filed for one or more quarters for which

this election is effective, the religious order (or

subdivision) must file Forms 941 for those

retroactive quarters.

See the current instructions for Form 941 or

941-X for the list of filing addresses.

Specific Instructions— 

Forms 941 and 941-X

IF the Form SS-16

is filed any day

during the . . .

Effective date (mm/dd/yyyy)

(See instructions on Copy C.)

1st quarter (January,

February, March)

Form 941-X. If original Forms 941 were filed

for any of the retroactive quarters for which

this election is effective, the religious order

must file Forms 941-X, Adjusted Employer’s

QUARTERLY Federal Tax Return or Claim for

Refund, for those retroactive quarters.

Form 944. If you were notified to file Form

944, Employer’s ANNUAL Federal Tax Return,

instead of Form 941, call the IRS for

assistance at 1-800-829-4933 (toll free). If you

have access to TTY/TDD equipment, call

1-800-829-4059 (toll free). If you are in a

foreign country, call 215-516-2000 (not toll

free).

Retroactive quarters. Under section 3121(r),

the due date of Forms 941 or 941-X for all

retroactive quarters is determined by the date

Form SS-16 is filed. The due date for filing

the returns and paying the tax, for calendar

quarters prior to the quarter in which Form

SS-16 is filed, is the last day of the calendar

month following the calendar quarter in which

Form SS-16 is filed. If you file and pay by the

applicable due date, you will not be subject

to failure to file or failure to pay penalties or

interest.

THEN all Forms 941 or

941-X for the retroactive

quarters must be filed

and tax paid by . . .

2nd quarter (April, 

May, June)

3rd quarter (July, 

August, September)

4th quarter (October,

November, December)

April 30

July 31

October 31

January 31 of next year

Postmark rule. For purposes of determining

when returns are due, generally the “received

date” is considered the date Form SS-16 is

filed. However, if the religious order selects an

effective date that is the first day of the 20th

calendar quarter preceding the quarter in

which Form SS-16 is postmarked but the

Form SS-16 is received in a later quarter, the

IRS will use the postmark date to determine

the date filed to ensure the intended 20th

quarter can be included.

How To File

Forms 941 for retroactive quarters. Enter

“Form SS-16” and the date you filed Form

SS-16 in dark, bold letters across the top

margin of page 1 of each Form 941 being

filed. Attach a copy of Form SS-16 to each

Form 941 filed for a retroactive quarter to

help identify that the return is being filed for

retroactive coverage. In the top margin of the

Form SS-16 being attached, enter “Copy” in

dark, bold letters.

You can get Forms 941 for the retroactive

quarters by phone, mail, or on the Internet.

Internal Revenue Service

1201 N. Mitsubishi Motorway

Bloomington, IL 61705-6613

Form 941-X. In the explanation in Part IV of

each Form 941-X, enter “Form SS-16” and

the date your Form SS-16 was filed.

If you are filing Form 941-X for any

retroactive quarter, use the current form. You

can get this form through any of the sources

listed above.

Additional information. See Pub. 15 (Circular

E), Employer’s Tax Guide, for more

information about filing or correcting Form

941 or 944. Also see the instructions for Form

941, 941-X, or 944.

(Print or type name of authorized official) (Telephone number)